What is the maximum recommended dose of Toradol (ketorolac)?

Maximum Dose of Toradol (Ketorolac)

The maximum daily dose of ketorolac is 120 mg/day for adults under 65 years, and 60 mg/day for patients ≥65 years, those with renal impairment, or weighing <50 kg (110 lbs), with treatment duration not to exceed 5 days. 1

Standard Dosing by Route and Patient Population

Adults <65 Years (≥50 kg body weight)

Intravenous Administration:

• Single dose: 30 mg 1
• Multiple doses: 30 mg every 6 hours 1
• Maximum daily dose: 120 mg 1

Intramuscular Administration:

• Single dose: 60 mg 1
• Multiple doses: 30 mg every 6 hours 1
• Maximum daily dose: 120 mg 1

High-Risk Populations (≥65 years, renal impairment, or <50 kg)

The maximum daily dose is reduced by 50% in elderly patients to 60 mg/day due to significantly elevated risk for renal, gastrointestinal, and cardiovascular toxicities. 2, 1

Intravenous Administration:

• Single dose: 15 mg 1
• Multiple doses: 15 mg every 6 hours 1
• Maximum daily dose: 60 mg 1

Intramuscular Administration:

• Single dose: 30 mg 1
• Multiple doses: 15 mg every 6 hours 1
• Maximum daily dose: 60 mg 1

Critical Duration Limitation

Ketorolac therapy must not exceed 5 days regardless of route of administration. 1, 3 This strict time limit exists because prolonged use substantially increases risks of gastrointestinal bleeding, renal toxicity, and cardiovascular complications 2, 4.

Administration Technique

• Intravenous bolus must be given over no less than 15 seconds 1
• Intramuscular administration should be given slowly and deeply into the muscle 1
• Onset of analgesia begins in approximately 30 minutes with maximum effect at 1-2 hours 1
• Duration of analgesic effect is typically 4-6 hours 1

Common Pitfall: Dosing Above the Analgesic Ceiling

Emergency physicians frequently prescribe ketorolac at 30-60 mg doses, but research demonstrates an analgesic ceiling effect at approximately 10 mg, meaning higher doses provide no additional pain relief while increasing toxicity risk. 5 A retrospective study of 49,605 administrations found that 97% of intravenous doses and 96% of intramuscular doses exceeded the 10 mg ceiling dose 5. Despite this evidence, the FDA-approved dosing remains at 15-30 mg per dose 1.

Absolute Contraindications

Do not administer ketorolac in patients with:

• Active peptic ulcer disease or gastrointestinal bleeding 2
• Cerebrovascular hemorrhage 2
• Severe renal impairment 2
• Concurrent anticoagulant therapy 2
• Aspirin/NSAID-induced asthma 2
• Concurrent use with other NSAIDs 2, 4

NSAID Stacking Warning

Never combine ketorolac with other NSAIDs (including ibuprofen, naproxen) as toxicities are additive without providing additional analgesic benefit. 4 If a patient has recently taken ibuprofen, wait 6-8 hours for drug clearance before administering ketorolac 4.

Mandatory Monitoring Requirements

Baseline assessment before initiating ketorolac:

• Blood pressure 2, 4
• BUN and creatinine 2, 4
• Complete blood count 2, 4
• Liver function tests 4
• Fecal occult blood 2, 4

Discontinue immediately if:

• BUN or creatinine doubles 4
• Hypertension develops or worsens 4
• Liver function tests increase >3 times upper limit of normal 4
• Gastrointestinal bleeding occurs 4

Breakthrough Pain Management

For breakthrough pain, do not increase the dose or frequency of ketorolac. 1 Instead, consider supplementing with low-dose opioids unless contraindicated 1. Ketorolac demonstrates marked opioid-sparing effects when combined with opioid analgesics 6.